ProBTP and Counter Fraud

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ProBTP and Counter Fraud
IBM Counter fraud Management client story
ProBTP and Counter Fraud
How to deal with a delicate corporate&society subject
© 2015
© 2015 IBM Corporation
IBM Corporation
Before starting …
© 2015 IBM Corporation
A little bit of background on :
Healthcare payers landscape in France
11.6%
Is the Part of the GDP for the Social Security expenditure
-24
From 1300 to 250
For Supplementary
Social
# : 2005
vs 2015
Security Companies
-9
Compulsory Social
Security
Supplementary
Social Security
• Concentration
• Stronger competition
•ButClearer
competition
…
© 2015 IBM Corporation
A little bit of background on :
The ProBTP context – Why to Industrialize Counter Fraud now (2013)
Activity
Fraud & Abuse Impact for ProBTP
Fraud
Compulsory Social
Security plan
• Switch : in 2013
• Better Understanding of financial impact
Risk
• Regulation evolution
• Difficulty to recover the money
Supplementary
Social Security
© 2015 IBM Corporation
Objective : Understand the value
ProtBTP conviction cycle
Start : 2013 June
POC : 2013 October– 3 weeks
Decision : 2013 December
Signature : Postponed (2013)
Before :
1% detected
& 15% Positive
In october : 10% detected
& 70% positive
X
X XX
Why not signed if decided ?
$
X
X
Pipe
Analysis
Data / Optic
2 years history
CFM Analytics
© 2015 IBM Corporation
Proof of value : 7%
• Great result
• Contract
But in november,
Predictive
on history approach
• Switch from a ProBTP
to based
a Market
Beneficiary information ….
Predictive – Anomaly detection
• ProBTP with IBM partnership
Heathcare profesionnals….
• Decision : Build a SaaS Business
for the
Rules market
• Claims
Signature in 2014 MarchIdentity & networks
Proof of concept : 10%
Supplementary
Social Security
X
Zoom on the solution to Counter Fraud & Abuse in Healthcare Payment process
Reminder : project has started on 2014 april
2018
• Roadmap : where we are – where we go
•
•
•
•
•
Oct 14 : Dental & Optical & PostPayment
May 15 : Pre Payment
Oct 15 : Audio & Medical Transport
June 16 : Medecine & Pharma
Oct 16 : Daily allowance
2017
2016
2015
2014
• Technical platform
• Based on IBM Counter Fraud Management
• Business Pack : Solon (Healthcare Fraud)
• Detection
• Fraud Score
• Alerte & Next best action
© 2015 IBM Corporation
SOLON: An externalized service platform (SaaS)
4 Mutuals (+)
Healthcare
Operator
Payment
Claims
3.1M
Benefiaries
7M Benefiaries
50k+
Professionals
90% Professionals
Platform
Solon
Immediate
6 monthPayback
Payback
250%
300%
ROIROI
(average)
Insurance against fraud
• Inbound :
1) Claims, practitioner’s dataset, contract rights.
2) Client feedback on claims and fraud detection (confirmed fraud / false positive)
• Outbound : results from the detection engine, configurations sets, action models
• Transaction access to the platform : reports, performance measurement
© 2015 IBM Corporation
Solon Combines 5 Analytical Engines
Profiling
1
2
Configurations,
Alerts,
Reports
Experience-based predictive modeling
(supervised learning mode)
3
Business rules and indicators
(existing experience & continuous
improvement)
Visual analysis of relationships
between insured/beneficiaries,
health providers, …
Action
Atypical traits detection
(anomaly detection)
5
4
© 2015 IBM Corporation
A view on the Solon capabilities
• Reporting / dashboard
• Understanding the detection within the application screens
• Investigating a case
© 2015 IBM Corporation
Solon : A Solution Against Frauds, Errors and Abuses
• Immediately operational
• Safety and confidentiality of your data.
• CFM & Expertise on Healthcare at IBM
• Community system to share the new fraud behavior indicators
& coordinate dissuasive actions
• An immediate return on investment
• A counter fraud observatory
© 2015 IBM Corporation
My « take away » proposal with Solon platform – ProBTP experience
• 1 to 10
France vs England Olympics medals average difference
A factor 10 efficiency for fraud detection
•7
Number of wonders of the world
% of TRUE fraud vs total claim reimbursement amount
• 300
Watson should have said : what is the Zack Snyder film?
% ROI with IBM Counter Fraud Management
• 3 to 7 millions
Evolution of my sales quota between H1 and H2
Evolution of beneficiaries # on the Solon SaaS platform
© 2015 IBM Corporation
Our commitment to a Safer Planet
© 2015 IBM Corporation
© 2015 IBM Corporation
PANEL Questions & Answer
© 2015 IBM Corporation

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